Search

Real-time polymerase chain reaction (RT-PCR) remains the gold standard for detection of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). This study tested the performance of a pooled testing strategy for RT-PCR and its cost-effectiveness. In total, 1280 leftover respiratory samples collected between 19 April and 6 May 2021 were tested in 128 pools of 10 samples each, out of which 16 pools were positive. The positivity rate of the unpooled samples was 1.9% (24/1280). After parallel testing using the individual and pooled testing strategies, positive agreement was 100% and negative agreement was 99.8%. The overall median cycle threshold (Ct) value of the unpooled samples was 29.8 (interquartile range 22.3–34.3). Pools that remained positive when compared with the results of individual samples had lower median Ct values compared with those that turned out to be negative (28.8 versus 34.8; P=0.0.035). Pooled testing reduced the cost >4-fold. Pooled testing may be a more cost-effective approach to diagnose SARS-CoV-2 in resource-limited settings without compromising diagnostic performance.

Objective Traditionally, health systems in sub-Saharan Africa have focused on acute conditions. Few data exist on the readiness of African health facilities (HFs) to address the growing burden of chronic diseases (CDs), specifically chronic, non-communicable diseases (NCDs). Methods A stratified random sample of 28 urban and rural Ugandan HFs was surveyed to document the burden of selected CDs by analysing the service statistics, service availability and service readiness using a modified WHO Service Availability and Readiness Assessment questionnaire. Knowledge, skills and practice in the management of CDs of 222 health workers were assessed through a self-completed questionnaire. Results Among adult outpatient visits at hospitals, 33% were for CDs including HIV vs. 14% and 4% at medium-sized and small health centres, respectively. Many HFs lacked guidelines, diagnostic equipment and essential medicines for the primary management of CDs; training and reporting systems were weak. Lower-level facilities routinely referred patients with hypertension and diabetes. HIV services accounted for most CD visits and were stronger than NCD services. Systems were weaker in lower-level HFs. Non-doctor clinicians and nurses lacked knowledge and experience in NCD care. Conclusion Compared with higher level HFs, lower-level ones are less prepared and little used for CD care. Health systems in Uganda, particularly lower-level HFs, urgently need improvement in managing common NCDs to cope with the growing burden. This should include the provision of standard guidelines, essential diagnostic equipment and drugs, training of health workers, supportive supervision and improved referral systems. Substantially better HIV basic service readiness demonstrates that improved NCD care is feasible. Objectif Traditionnellement, les systemes de sante en Afrique subsaharienne ont mis l'accent sur les maladies aigues. Peu de donnees existent sur l’etat d'appretement des etablissements de sante (ES) africains pour faire face a la charge croissante des maladies chroniques (MC), specifiquement chroniques, les maladies non transmissibles (MNT). Methodes Un echantillon aleatoire stratifie de 28 ES urbains et ruraux ougandais a ete interroge pour documenter la charge de MC selectionnees, en analysant les statistiques des services, la disponibilite des services et l'appretement des services a l'aide d'un questionnaire SARA modifie de l’OMS. Les connaissances, competences et pratiques dans la prise en charge des MC de 222 agents de la sante ont ete evaluees par le biais d'un questionnaire auto-administre. Resultats Parmi les visites ambulatoires d'adultes dans les hopitaux, 33% etaient pour des MC dont le VIH, contre 14% et 4% dans les centres de sante de taille moyenne et petite, respectivement. Beaucoup d’ES manquaient de directives, de materiel de diagnostic et des medicaments essentiels pour la prise en charge primaire des MC; les systemes de formation et de report etaient faibles. Les etablissements de niveau inferieur referaient couramment les patients souffrant d'hypertension et de diabete. Les services VIH enregistraient la plupart des visites de MC et etaient plus prepares que les services des MNT. Les systemes etaient moins prepares dans les ES de niveau inferieur. Les cliniciens non-medecins et les infirmier(e)s manquaient de connaissances et d'experience dans les soins des MNT. Conclusion Compares aux ES de niveau superieur, ceux de niveau inferieur sont moins bien prepares et peu utilises pour les soins de MC. Les systemes de sante en Ouganda, particulierement les ES de niveau inferieur, ont urgemment besoin d'amelioration pour la prise en charge des MNT courantes afin de pouvoir faire face a la charge croissante. Cela devrait inclure la fourniture de directives standard, l’equipement de diagnostic et les medicaments essentiels, la formation des agents de sante, la supervision formative et l'amelioration des systemes d'aiguillage. L'appretement substantiellement meilleur des services VIH de base demontre que l'amelioration des soins des MNT est faisable. Objetivo Tradicionalmente, los sistemas sanitarios en Africa subsahariana se han centrado en condiciones agudas. Existen pocos datos sobre el nivel de preparacion de los centros sanitarios (CS) africanos para afrontar la cada vez mayor carga de enfermedades cronicas (EC), especificamente las enfermedades cronicas no transmisibles (ECNs). Metodos Se evaluo una muestra estratificada y aleatoria de 28 SC urbanos y rurales de Uganda, para documentar la carga de ECs mediante el analisis de estadisticas del servicio, disponibilidad de servicios y nivel de preparacion de los servicios utilizando una modificacion del cuestionario SARA de la OMS. Se evaluaron los conocimientos, las capacidades y las practicas en el manejo de las ECs de 222 trabajadores sanitarios mediante un cuestionario autocompletado. Resultados Entre los adultos que visitaron los hospitales como pacientes externos, un 33% lo hizo por ECs incluyendo VIH versus 14% y 4% en centros sanitarios de tamano medio y pequeno, respectivamente. En muchos CSs habia una falta de guias, equipos de diagnostico y medicamentos esenciales para el manejo primario de ECs; los sistemas de formacion e informes eran debiles. Los centros de menor nivel referian a sus pacientes con hipertension y diabetes de forma rutinaria. Los servicios de VIH recibian la mayoria de las visitas por ECs y eran mas fuertes que los servicios para ECNs. Los sistemas eran mas debiles en CSs de menor nivel. Los sanitarios no medicos y las enfermeras no tenian ni los conocimientos ni la experiencia para la atencion de ECN. Conclusion Comparado con CS de mayor nivel, los de menor nivel estan menos preparados y poco acostumbrados a la atencion de ECs. Los sistemas sanitarios en Uganda, en particular los CS de menor nivel, necesitan mejorar urgentemente el manejo de ECN para afrontar una carga que va en aumento. Ello incluye contar con guias estandarizadas, equipos de diagnostico y medicamentos esenciales, entrenamiento de los trabajadores sanitarios, supervision de apoyo y sistemas de referencia mejorados. Unos servicios de atencion basica al VIH sustancialmente mejores son la prueba de que es factible contar con una atencion mejorada de las ECN.

Objective To explore the chronic disease services in Uganda: their level of utilisation, the total service costs and unit costs per visit. Methods Full financial and economic cost data were collected from 12 facilities in two districts, from the provider's perspective. A combination of ingredients‐based and step‐down allocation costing approaches was used. The diseases under study were diabetes, hypertension, chronic obstructive pulmonary disease (COPD), epilepsy and HIV infection. Data were collected through a review of facility records, direct observation and structured interviews with health workers. Results Provision of chronic care services was concentrated at higher‐level facilities. Excluding drugs, the total costs for NCD care fell below 2% of total facility costs. Unit costs per visit varied widely, both across different levels of the health system, and between facilities of the same level. This variability was driven by differences in clinical and drug prescribing practices. Conclusion Most patients reported directly to higher‐level facilities, bypassing nearby peripheral facilities. NCD services in Uganda are underfunded particularly at peripheral facilities. There is a need to estimate the budget impact of improving NCD care and to standardise treatment guidelines.

Objective To assess the long-term effects of population-level HSV-2 infection on HIV incidence. Methods Data from a population-based cohort in south-western Uganda were used to estimate HIV incidence from 1990 to 2007. Stored blood samples were tested for HSV-2, and the impact of HSV-2 prevalence and incidence on HIV incidence was estimated by calculating population attributable fractions (PAFs). The association between population-level annual HIV incidence and annual HSV-2 incidence/prevalence was analysed using linear regression. Results HIV incidence declined over time among men, from 8.72/1000 person-years (pyr) in 1990 to 4.85/1000 pyr in 2007 (P-trend

The General Population Cohort (GPC) was set up in 1989 to examine trends in HIV prevalence and incidence, and their determinants in rural south-western Uganda. Recently, the research questions have included the epidemiology and genetics of communicable and non-communicable diseases (NCDs) to address the limited data on the burden and risk factors for NCDs in sub-Saharan Africa. The cohort comprises all residents (52% aged ≥13years, men and women in equal proportions) within one-half of a rural sub-county, residing in scattered houses, and largely farmers of three major ethnic groups. Data collected through annual surveys include; mapping for spatial analysis and participant location; census for individual socio-demographic and household socioeconomic status assessment; and a medical survey for health, lifestyle and biophysical and blood measurements to ascertain disease outcomes and risk factors for selected participants. This cohort offers a rich platform to investigate the interplay between communicable diseases and NCDs. There is robust infrastructure for data management, sample processing and storage, and diverse expertise in epidemiology, social and basic sciences. For any data access enquiries you may contact the director, MRC/UVRI, Uganda Research Unit on AIDS by email to mrc@mrcuganda.org or the corresponding author.

Because the incidence of human immunodeficiency virus (HIV) infection is difficult to measure directly, prevalence trends often serve to track epidemiologic changes. Adult HIV prevalence in open population cohort studies, however, reflects changes in incidence, population factors (migration, deaths, and aging), and survey coverage. Data from an open cohort in rural Uganda enabled estimation of the contribution of these factors to prevalence trends from 1989 to 2007. New infections within this cohort represented on average 44% of new prevalent cases per year. Other factors affecting changes in prevalence included migration and death. Migrants and mobile people (those who leave and return to the study area) are in a higher-risk group and thus can affect prevalence trends. Incidence of HIV infection among mobile people was 2-4 times greater than among stable residents. The importance of mortality is shown by the rise in prevalence from 6.8% in 2005 to 7.4% in 2007, which was accompanied by a fall in mortality among HIV-infected participants (8.7% of HIV-infected in 2005, 5.2% in 2006, and 4.3% in 2007). Assessing HIV epidemic trends through prevalence requires consideration of population factors. Measuring HIV incidence directly remains the most accurate measure of trends with which to monitor the effect of intervention activities and should complement strategies such as national prevalence surveys.

Objective: To describe sexual behaviour trends in a rural Ugandan cohort in the context of an evolving HIV epidemic, 1993–2006. Methods: Sexual behaviour data were collected annually from a population cohort in which HIV serological surveys were also conducted. Behaviour trends were determined using survival analysis and logistic regression. Trends are reported based on the years in which the respective indicators were collected. Results: Between 1993 and 2006, median age at first sex increased from 16.7 years to 18.2 years among 17–20-year-old girls and from 18.5 years to 19.9 years among boys. Both sexes reported a dip in age at sexual debut between 1998 and 2001. One or more casual partners in the past 12 months among men rose from 11.6% in 1997 to 12.7% in 2004 and then declined to 10.2% in 2006. Among women it increased from 1.4% in 1997 to 3.7% in 2004 and then reduced to 1.4% in 2006. The rise in casual partners between 1997 and 2004 was driven mainly by older age groups. Trends in condom use with casual partners varied by age, increasing among those aged 35+ years, declining in the middle age groups and presenting a dip and then a rise in the youngest aged group (13–19 years). Conclusion: Among youth, risky behaviour declined but increased in the late 1990s/early 2000s. Among those aged 35+ years, condom use rose but casual partners also rose. Several indicators portrayed a temporary increase in risk taking behaviour from 1998 to 2002.

Two significant challenges face researchers tracking HIV-related socio-economic and demographic change over time in large cohort studies. Firstly, data collected in cohort studies established to describe the dynamics of HIV infection may contain no systematic data on household consumption expenditures which is an established measure of current and long-run household welfare. The second challenge is the choice of the unit of analysis in order to recognise and record impact; this is because most cohorts use the household as that unit. This means that the influence of factors outside that unit cannot easily be tracked. In this paper we show how a detailed understanding of the impact of HIV and AIDS on wider families and social networks, obtained through in-depth longitudinal research with a small number of households, can shed light on the findings from quantitative analysis from a larger cohort in the same population in rural Uganda. The findings of large-scale survey data from more than 2000 households over a 12-year period showed a lack of a strong association between poverty, HIV status and/or death of the household head. In-depth ethnographic research with 26 households in 1991/2 and a restudy of the same households in 2006/7 provide insights into the reasons for this finding: the choice of socio-economic indicators and support from other family and community members play a part in affecting survey findings on the impact of HIV at household level. One other factor is important in explaining the findings. HIV-infected family members from outside the household may drain resources from the household, so looking at the impact of HIV and AIDS on people's wider families provides pointers to why those who have not had an AIDS-related death in their own household may have failed to prosper. Our qualitative findings show that AIDS may well throw households into disarray and poverty, but more often reduces development and hinders families from getting out of poverty. Used strategically, small longitudinal studies can provide important information with which to explain patterns observed in large-scale quantitative datasets.

Throughout the 1990s, HIV-1 prevalence and incidence were falling in Uganda. Recently, some researchers have noticed that HIV-1 prevalence is levelling off. We examine prevalence, incidence, and sexual behaviour trends in a rural population cohort in Uganda over 16 years.We report prevalence by survey round and incidence by calendar year from a prospective general population cohort study. Using logistic regression Wald tests, we examined casual partners, condom use, and pregnancies. We examined age at sexual debut by means of life tables.HIV-1 prevalence declined from 8.5% in 1990/1991 to 6.2% in 1999/2000, and thereafter rose to 7.7% in 2004/2005. Incidence (per 1000 person-years at risk) fell from 7.5 in 1990 to 4.1 in 1998, and thereafter increased to 5.0 by 2004. The 2005 incidence estimate reached an all-time low of 2.5, but the preliminary 2006 estimate shows a rise again. Incidence trends varied by age and sex. Some sexual behaviour indicators showed more risky behaviour in recent years compared with the 1990s, whereas others indicated that the reduction in risky behaviour that began in the 1990s continues.HIV-1 prevalence is rising in this cohort. Incidence is stabilizing, and shows signs of increasing among some subgroups. The extent to which changing sexual behaviour has played a role in these epidemiological trends is unclear, but it is likely to have contributed. To solidify the success that Uganda had throughout the 1990s in controlling the HIV epidemic, the efforts in HIV prevention need to be re-strengthened, using all strategies known.

Objectives: Describe age-specific mortality patterns of HIV-infected adults in African communities before introduction of HAART. Methods: Mortality data (deaths and person-years observed) for HIV-positive subjects aged 15-65 from six African community studies in five different countries were pooled, combining information from 1793 seroconverters and 8534 HIV positive when first tested. Age-specific mortality hazards were modelled using parametric regression based on the Weibull distribution, to investigate effects of sex, and site-specific measures of mean age at incidence, crude mortality rate of uninfected, and measures of epidemic maturity. Results: The combined studies yielded a total of 31 777 person-years of observation for HIV-positive subjects, during which time 2602 deaths were recorded. Mortality rates rose almost linearly with age, from below 50/1000 at ages < 20 years, up to 150/1000 at 50 years +. There was no significant difference between men and women in level or age pattern of mortality. Weibull regression analysis suggested that intersite variation could be explained by HIV prevalence trend, and by the ratio of HIV proportional mortality to current HIV prevalence. A model representation was constructed with a common age pattern of mortality, but allowing the level to be adjusted by specifying HIV prevalence indicators. Conclusion: The linear age trend of mortality in HIV-infected populations was satisfactorily represented by a Weibull function providing a parametric model adaptable for representing different levels of HIV-related mortality. This model might be simpler to use in demographic projections of HIV-affected populations than models based on survival post-infection.

Assessments of the importance of different routes of HIV-1 (HIV) transmission are vital for prioritization of control efforts. Lack of consistent direct data and large uncertainty in the risk of HIV transmission from HIV-contaminated injections has made quantifying the proportion of transmission caused by contaminated injections in sub-Saharan Africa difficult and unavoidably subjective. Depending on the risk assumed, estimates have ranged from 2.5% to 30% or more. We present a method based on an age-structured transmission model that allows the relative contribution of HIV-contaminated injections, and other routes of HIV transmission, to be robustly estimated, both fully quantifying and substantially reducing the associated uncertainty. To do this, we adopt a Bayesian perspective, and show how prior beliefs regarding the safety of injections and the proportion of HIV incidence due to contaminated injections should, in many cases, be substantially modified in light of age-stratified incidence and injection data, resulting in improved (posterior) estimates. Applying the method to data from rural southwest Uganda, we show that the highest estimates of the proportion of incidence due to injections are reduced from 15.5% (95% credible interval) (0.7%, 44.9%) to 5.2% (0.5%, 17.0%) if random mixing is assumed, and from 14.6% (0.7%, 42.5%) to 11.8% (1.2%, 32.5%) under assortative mixing. Lower, and more widely accepted, estimates remain largely unchanged, between 1% and 3% (0.1–6.3%). Although important uncertainty remains, our analysis shows that in rural Uganda, contaminated injections are unlikely to account for a large proportion of HIV incidence. This result is likely to be generalizable to many other populations in sub-Saharan Africa.

Introduction Due to a limited health workforce, many health care providers in Africa must take on health leadership roles with minimal formal training in leadership. Hence, the need to equip health care providers with practical skills required to lead high-impact health care programs. In Uganda, the Afya Bora Global Health Leadership Fellowship is implemented through the Makerere University College of Health Sciences (MakCHS) and her partner institutions. Lessons learned from the program, presented in this paper, may guide development of in-service training opportunities to enhance leadership skills of health workers in resource-limited settings. Methods The Afya Bora Consortium, a consortium of four African and four U.S. academic institutions, offers 1-year global health leadership-training opportunities for nurses and doctors. Applications are received and vetted internationally by members of the consortium institutions in Botswana, Kenya, Tanzania, Uganda, and the USA. Fellows have 3 months of didactic modules and 9 months of mentored field attachment with 80% time dedicated to fellowship activities. Fellows’ projects and experiences, documented during weekly mentor-fellow meetings and monthly mentoring team meetings, were compiled and analyzed manually using pre-determined themes to assess the effect of the program on fellows’ daily leadership opportunities. Results Between January 2011 and January 2015, 15 Ugandan fellows (nine doctors and six nurses) participated in the program. Each fellow received 8 weeks of didactic modules held at one of the African partner institutions and three online modules to enhance fellows’ foundation in leadership, communication, monitoring and evaluation, health informatics, research methodology, grant writing, implementation science, and responsible conduct of research. In addition, fellows embarked on innovative projects that covered a wide spectrum of global health challenges including critical analysis of policy formulation and review processes, bottlenecks in implementation of national HIV early infant diagnosis and prevention of mother-to-child HIV-transmission programs, and use of routine laboratory data about antibiotic resistance to guide updates of essential drug lists. Conclusion In-service leadership training was feasible, with ensured protected time for fellows to generate evidence-based solutions to challenges within their work environment. With structured mentorship, collaborative activities at academic institutions and local health care programs equipped health care providers with leadership skills. Electronic supplementary material The online version of this article (doi:10.1186/s12960-015-0087-2) contains supplementary material, which is available to authorized users.

Summary Background The six-dose regimen of artemether-lumefantrine is effective and is among combination therapies prioritised to replace antimalarials that no longer work in Africa. However, its effectiveness has not been assessed in the field, and could be compromised by poor adherence, incorrect timing of doses, and insufficient intake of fatty foods with every dose. Our aim, therefore, was to assess the effectiveness of artemether-lumefantrine prescribed under routine outpatient conditions, compared with its efficacy when given under supervision to inpatients with acute uncomplicated falciparum malaria. Methods We did a randomised trial to compare the efficacy, safety, and pharmacokinetics of artemether-lumefantrine when given in a supervised (all doses observed with fatty-food intake; n=313) or unsupervised (first dose supervised followed by outpatient treatment with nutritional advice; n=644) setting to patients of all ages (weight >10 kg) with acute, uncomplicated falciparum malaria in Mbarara, Uganda. Our primary endpoint was 28 day, PCR-adjusted, parasitological cure rate. Analysis was by intention to treat and evaluability analysis. Findings 38 patients were lost to follow-up and one withdrew consent. Day-28 cure rates were 97·7% (296 of 303) and 98·0% (603 of 615) in the supervised and unsupervised groups, respectively. We recorded 15 non-severe, drug-related adverse events, all of which resolved. Interpretation Artemether-lumefantrine has a high cure rate irrespective of whether given under supervision with food or under conditions of routine clinic practice. If used as first-line treatment, artemether-lumefantrine could make a substantial contribution to malaria control in Africa, though cost is an issue.

Measuring baseline levels of adherence and identifying risk factors for non-adherence are important steps before the introduction of new antimalarials. In Mbarara in southwestern Uganda, we assessed adherence to artemether-lumefantrine (Coartem) in its latest World Health Organization blister formulation. Patients with uncomplicated Plasmodium falciparum malaria were prescribed artemether-lumefantrine and received an explanation of how to take the following five doses at home. A tablet count was made and a questionnaire was completed during a home visit. Among 210 analyzable patients, 21 (10.0%) were definitely or probably non-adherent, whereas 189 (90.0%) were probably adherent. Age group was not associated with adherence. Lack of formal education was the only factor associated with non-adherence after controlling for confounders (odds ratio = 3.1, 95% confidence interval [CI] = 1.1-9.7). Mean lumefantrine blood levels were lower among non-adherent (n = 16) (2.76 microg/mL, 95% CI = 1.06-4.45) than among adherent (n = 171) (3.19 microg/mL, 95% CI = 2.84-3.54) patients, but this difference was not statistically significant. The high adherence to artemether-lumefantrine found in our study suggest that this drug is likely to be very effective in Mbarara provided that patients receive clear dosage explanations.

BackgroundResearch has shown that health system utilization is low for chronic diseases (CDs) other than HIV. We describe the knowledge and perceptions of CDs identified from rural and urban communities in north-west Tanzania and southern Uganda.MethodsData were collected through a quantitative population survey, a quantitative health facility survey and focus group discussions (FGDs) and in-depth interviews (IDIs) in subgroups of population survey participants. The main focus of this paper is the findings from the FGDs and IDIs.ResultsWe conducted 24 FGDs, involving approximately 180 adult participants and IDIs with 116 participants (≥18 years). CDs studied included: asthma/chronic obstructive lung disease (COPD), diabetes, epilepsy, hypertension, cardiac failure and HIV- related disease. The understanding of most chronic conditions involved a combination of biomedical information, gleaned from health facility visits, local people who had suffered from a complaint or knew others who had and beliefs drawn from information shared in the community. The biomedical contribution shows some understanding of the aetiology of a condition and the management of that condition. However, local beliefs for certain conditions (such as epilepsy) suggest that biomedical treatment may be futile and therefore work counter to biomedical prescriptions for management.ConclusionCurrent perceptions of selected CDs may represent a barrier that prevents people from adopting efficacious health and treatment seeking behaviours. Interventions to improve this situation must include efforts to improve the quality of existing health services, so that people can access relevant, reliable and trustworthy services.

BACKGROUND: Although there has been substantial global progress in decreasing child mortality over the past two decades, progress in sub-Saharan Africa has largely lagged behind. The temporal trends in child mortality and associated risk factors were investigated in a cohort of children in rural Uganda. METHODS: Information on children's vital status, delivery, breastfeeding, vaccination history, maternal vital and HIV status, and children's HIV status for 1993-2007 was retrieved from the Medical Research Council/Uganda Virus Research Institute's (MRC/UVRI) Annual Population Census and Survey in Uganda. Regression models were employed to assess the association of these factors with child mortality. RESULTS: From 1993 to 2007, the death rate (/1000 person-years) in children

BACKGROUND: Early initiation of antiretroviral therapy reduces risk of transmission to the uninfected partner in HIV discordant couples, but there are relatively little observational data on HIV transmission within couples from non-trial settings. The aims of this paper are to estimate HIV incidence among HIV discordant couples using longstanding observational data from a rural Ugandan population and to identify factors associated with HIV transmission within couples, including the role of HSV-2 infection. METHODS: Using existing data collected at population-wide annual serological and behavioural surveys in a rural district in southwest Uganda between 1989 and 2007, HIV discordant partners were identified. Stored serum samples were tested for HSV-2 serostatus using the Kalon ELISA test. HIV seroconversion rates and factors association with HIV seroconversion were analysed using Poisson regression. RESULTS: HIV status of both partners was known in 2465 couples and of these 259 (10.5%) were HIV serodiscordant. At enrollment, HSV-2 prevalence was 87.3% in HIV positive partners and 71.5% in HIV negative partners. Of the 259 discordant couples, 62 converted to HIV (seroconversion rate 7.11/100 PYAR, 95%CI; 5.54, 9.11) with the rate decreasing from 10.89 in 1990-1994 to 4.32 in 2005-2007. Factors independently associated with HIV seroconversion were female sex, non-Muslim religion, greater age difference (man older than woman by more than 15 years), higher viral load in the positive partner and earlier calendar period. HSV-2 was not independently associated with HIV acquisition (HR 1.62, 95%CI; 0.57, 4.55) or transmission (HR 0.61, 95%CI; 0.24, 1.57). No transmissions occurred in the 29 couples where the index partner was on ART during follow up (872 person-years on ART). DISCUSSION: HIV negative partners in serodiscordant couples have a high incidence of HIV if the index partner is not on antiretroviral therapy and should be provided with interventions such as couple counselling, condoms and antiretroviral treatment.

Several commercial type-specific serologic tests are available for herpes simplex virus type 2 (HSV-2). Poor specificity of some tests has been reported on samples from sub-Saharan Africa.To summarize the performance of the tests using samples from sub-Saharan Africa, we conducted a systematic review of publications reporting performance of commercially available HSV-2 tests against a gold standard (Western Blot or monoclonal antibody-blocking EIA). We used random-effects meta-analyses to summarize sensitivity and specificity of the 2 most commonly evaluated tests, Kalon gG2 enzyme-linked immunosorbent assay (ELISA), and Focus HerpeSelect HSV-2 ELISA.We identified 10 eligible articles that included 21 studies of the performance of Focus, and 12 of Kalon. The primary analyses included studies using the manufacturers' cut-offs (index value = 1.1). Focus had high sensitivity (random effects summary estimate 99%, 95% confidence interval [CI]: 99%-100%) but low specificity (69%, 95% CI: 59%-80%). Kalon had sensitivity of 95% (95% CI: 93%-97%) and specificity of 91% (95% CI: 86%-95%). Specificity of Focus was significantly lower (P = 0.002) among HIV-positive (54%, 95% CI: 40%-68%) than HIV-negative individuals (69%, 95% CI: 56%-82%). When the cut-off optical density index was increased above the recommended value of 1.1 to between 2.2 and 3.5, the specificity of Focus increased to 85% (95% CI: 77%-92%).Sensitivity and specificity of HSV-2 tests used in sub-Saharan Africa vary by setting, and are lower than reported from studies in the United States and Europe. Increasing the cut-off optical density index may improve test performance. Evaluation of test performance in a given setting may help deciding which test is most appropriate.

OBJECTIVES: To assess the nutritional status of children in a rural community with high HIV prevalence in rural Uganda and to examine the impact of HIV infection at the individual and population level. Methods Cross-sectional population-based survey of children aged 0-12 in a cohort comprising the residents of 25 neighbouring villages in rural southwest Uganda. Anthropometric indicators of nutritional status (height for age, weight for age and weight for height) were assessed in relation to children's HIV serostatus, maternal HIV serostatus and maternal vital status. Children with a Z score of

There is increasing consensus on the importance of strengthening global health research to meet health and development goals. Three key global health research aims are to ensure that research (i) addresses priority health needs, (ii) contributes to policy development, and (iii) adds value to investments in developing countries through South-South collaboration and capacity-strengthening in the South. The ALPHA network (Analysing Longitudinal Population-based HIV/AIDS data on Africa) is an illustrative example of how these global health research aims can be translated into action. The network facilitates additional collaborative HIV epidemiological research among six independent research projects in Africa studying population-based cohorts. Under the first of the earlier mentioned aims, the network addresses key epidemiology research issues in HIV/AIDS which are crucial to making progress and monitoring progress in the response against HIV/AIDS. Under the second aim, the network's scientific programme of research has contributed to strengthening the evidence base on HIV epidemiology in Africa and has informed policy development in areas such as targeted HIV prevention, social support, monitoring epidemic response and epidemic forecasting. Under the third aim, investment in the network has added value to the research investment in the individual projects through capacity development among African researchers as well as through the collaborative research outputs of the individual projects. Lessons from the network are relevant to collaborations facing similar challenges in other areas of global health research. These include the importance of establishing transparent and efficient governance for research collaborations, developing advance consensus on data sharing, ensuring effective communication for networking and demonstrating the added value of research investment in South-South collaborations.

Objectives: To estimate survival patterns after HIV infection in adults in low and middle-income countries. Design: An analysis of pooled data from eight different studies in six countries. Methods: HIV seroconverters were included from eight studies (three population-based, two occupational, and three clinic cohorts) if they were at least 15 years of age, and had no more than 4 years between the last HIV-negative and subsequent HIV-positive test. Four strata were defined: East African cohorts; South African miners cohort; Thai cohorts; Haitian clinic cohort. Kaplan-Meier functions were used to estimate survival patterns, and Weibull distributions were used to model and extend survival estimates. Analyses examined the effect of site, age, and sex on survival. Results: From 3823 eligible seroconverters, 1079 deaths were observed in 19671 person-years of follow-up. Survival times varied by age and by study site. Adjusting to age 25-29 years at seroconversion, the median survival was longer in South African miners: 11.6 years [95% confidence interval (Cl) 9.8-13.7] and East African cohorts: 11.1 years (95% Cl 8.7-14.2) than in Haiti: 8.3 years (95% Cl 3.2-21.4) and Thailand: 7.5 years (95% Cl 5.4-10.4). Survival was similar for men and women, after adjustment for age at seroconversion and site. Conclusion: Without antiretroviral therapy, overall survival after HIV infection in African cohorts was similar to survival in high-income countries, with a similar pattern of faster progression at older ages at seroconversion. Survival appears to be significantly worse in Thailand where other, unmeasured factors may affect progression.

To estimate mortality directly attributable to HIV in HIV-infected adults in low and middle income countries and discuss appropriate methodology.: Illustrative analysis of pooled data from six studies across sub-Saharan Africa and Thailand with data on individuals with known dates of seroconversion to HIV.Five of the studies also had data from HIV-negative subjects and one had verbal autopsies. Data for HIV-negative cohorts were weighted by the initial age and sex distribution of the seroconverters. Using the survival of the HIV-negative group to represent the background mortality, net survival from HIV was calculated for the seroconverters using competing risk methods. Mortality from all causes and 'net' mortality were modelled using piecewise exponential regression. Alternative approaches are explored in the dataset without information on mortality of uninfected individuals.The overall effect of the net mortality adjustment was to increase survivorship proportionately by 2 to 5% at 6 years post-infection. The increase ranged from 2% at ages 15-24 to 22% in those 55 and over. Mortality rate ratios between sites were similar to corresponding ratios for all-cause mortality.Differences between HIV mortality in different populations and age groups are not explained by differences in background mortality, although this does appear to contribute to the excess at older ages. In the absence of data from uninfected individuals in the same population, model life tables can be used to calculate background rates.

Thirty-six incident HIV cases were matched for age, sex and time period with 36 controls to examine associations with recent injections. A significant association between HIV incidence and a history of injections was detected that was not reduced after adjusting for available sexual behaviour variables. This association could either be the result of injections causing HIV infection or, more likely, injections for seroconversion illnesses or other consequences of unsafe sex.

Objectives: To determine the probable route of transmission of HIV to children aged 12 years or younger in a rural area of Uganda from 1999 through 2000 and to examine associations between HIV infection and health care-related variables. Methods: The HIV infections status for 6991 children was determined from 1 round of an ongoing population surveillance system, and the reported numbers of injections in the past year and blood transfusions were determined for 5922 of these children based on a medical questionnaire. Data from the surveillance system and from an additional survey were used to assess the potential for vertical infection from a mother to her child. Results: The HIV prevalence among children was 0.4%. Of 23 definite and 4 probable cases of HIV infection in children, vertical transmission was not possible for 1 case, not likely for another case, and possibly not vertical for another case. The population-attributable fraction for vertical transmission was between 90% and 94%. Large numbers of injections in the past year and ever having a blood transfusion were only associated with HIV infection in children exposed to vertical transmission. Conclusions: Up to 10% of HIV infections in children in the study area were not attributable to vertical transmission, and thus were possibly attributable to iatrogenic transmission. Associations seen between health care-related variables and HIV were likely to be attributable to treatment for AIDS-related illness in children infected vertically.

Background A six-dose antimalarial regimen of artemether-lumefantrine (A/L) may soon become one of the most widely used drug combination in Africa, despite possible constraints with adherence and poor absorption due to inadequate nutrition, and a lack of pharmacokinetic and effectiveness data. Methods Within a trial of supervised versus unsupervised A/L treatment in a stable Ugandan Plasmodium falciparum transmission setting, plasma lumefantrine concentrations were measured in a subset of patients on day 3 (C [lum]day3) and day 7 (C [lum]day7) post-inclusion. Predictors of lumefantrine concentrations were analysed to show how both C [lum]day7 and the weight-adjusted lumefantrine dose affect 28-day recrudescence and re-infection risks. The implications of these novel findings are discussed in terms of the emergence of lumefantrine-resistant strains in Africa. Results C [lum]day3 and C [lum]day7 distributions among 241 supervised and 238 unsupervised patients were positively skewed. Unsupervised treatment and decreasing weight-adjusted lumefantrine dose were negatively associated with C [lum]day3. Unsupervised treatment and decreasing age showed strong negative associations with C [lum]day7. Both models were poorly predictive (R-squared < 0.25). There were no recrudescences in either arm, but decreasing lumefantrine dose per Kg resulted in up to 13-fold higher adjusted risks of re-infection. Re-infections occurred only among patients with C [lum]day7 below 400 ng/mL (p < 0.001). Conclusion Maintaining the present six-dose regimen and ensuring high adherence and intake are essential to maximize the public health benefits of this valuable drug combination.

In sub-Saharan Africa, cryptococcosis is a frequent opportunistic infection and a major cause of death in patients with AIDS. 1,2 The disease is mainly recognized at the neuromeningitis stage and is diagnosed by microscopy and culture of cerebrospinal fluid (CSF). The identification of cryptococcal antigen (CRAG) by latex particle agglutination is highly sensitive, 3,4 and this technique is used routinely in Western countries. We evaluated the prevalence of CRAG in serum samples from adults with clinically advanced HIV infection and the proportion of CRAG-positive patients with neuromeningitis.

Background HIV surveillance of generalised epidemics in Africa primarily relies on prevalence at antenatal clinics, but estimates of incidence in the general population would be more useful. Repeated cross-sectional measures of HIV prevalence are now becoming available for general populations in many countries, and we aim to develop and validate methods that use these data to estimate HIV incidence. Methods and Findings Two methods were developed that decompose observed changes in prevalence between two serosurveys into the contributions of new infections and mortality. Method 1 uses cohort mortality rates, and method 2 uses information on survival after infection. The performance of these two methods was assessed using simulated data from a mathematical model and actual data from three community-based cohort studies in Africa. Comparison with simulated data indicated that these methods can accurately estimates incidence rates and changes in incidence in a variety of epidemic conditions. Method 1 is simple to implement but relies on locally appropriate mortality data, whilst method 2 can make use of the same survival distribution in a wide range of scenarios. The estimates from both methods are within the 95% confidence intervals of almost all actual measurements of HIV incidence in adults and young people, and the patterns of incidence over age are correctly captured. Conclusions It is possible to estimate incidence from cross-sectional prevalence data with sufficient accuracy to monitor the HIV epidemic. Although these methods will theoretically work in any context, we have able to test them only in southern and eastern Africa, where HIV epidemics are mature and generalised. The choice of method will depend on the local availability of HIV mortality data., Timothy Hallett and colleagues develop and test two user-friendly methods to estimate HIV incidence based on changes in cross-sectional prevalence, using either mortality rates or survival after infection., Editors' Summary Background. More than 25 million people have died from AIDS and about 33 million people are currently infected with human immunodeficiency virus (HIV, the virus that causes AIDS). Faced with this threat to human health, governments and international agencies are working together to halt the AIDS epidemic. An important part of this effort is HIV surveillance. The spread of HIV needs to be monitored to assess the impact of interventions (for example, the provision of antiretroviral drugs) and to plan for current and future health care needs. HIV surveillance in countries where the epidemic has spread beyond specific groups into the whole population (a generalized epidemic) has mainly relied on determining the prevalence of HIV infection (the fraction of the population that is infected) among women attending antenatal clinics. Recently, however, household health surveys (for example, the Demographic and Health Surveys) have begun to use blood testing for antibodies to the AIDS virus (serological testing) to provide more accurate estimates of HIV prevalence in the general adult population. Why Was This Study Done? Although prevalence estimates provide useful information about the HIV epidemic, another important indicator is incidence—the number of new infections occurring during a specific time period. Incidence measurements provide more information about temporal changes in the epidemic and transmission patterns and allow public-health experts to make better predictions of future health care needs. But, whereas prevalence can be measured with anonymized serological surveys, individuals would have to be identified and followed up in repeat serological surveys to provide a direct measurement of incidence. This is expensive and hard to achieve in many settings. In this study, therefore, the researchers develop and validate two mathematical methods to estimate HIV incidence in generalized HIV epidemics from prevalence data. What Did the Researchers Do and Find? Changes in the fraction of the population living with HIV (prevalence) can occur not only because of changes in the rate of new infections (incidence), but also because mortality rates are much higher for infected individuals than others. The researchers' methods disentangle the contributions to HIV prevalence (as measured in serological surveys) made by new infections from those due to deaths from AIDS and other causes. Their first method incorporates information on death rates collected in cohort studies of HIV infection (cohort studies investigate outcomes in groups of people); their second method uses information on survival after HIV infection, also collected in long-running cohort studies. The accuracy of both methods was assessed using computer-simulated data and actual data on HIV prevalence and incidence collected in three community-based cohort studies in Zimbabwe and Uganda (countries with generalized but declining HIV epidemics) and Tanzania (a country with a generalized, stable epidemic). Both methods provided accurate estimates of HIV incidence from the simulated data. Using the data collected in Africa, the mean difference between actual measurements of incidence and the estimate provided by method 1 was 19%; for method 2 it was 14%. In addition, the measured and estimated incidences were in good agreement for all age groups. What Do These Findings Mean? These findings suggest HIV incidence rates can be estimated from repeat surveys of prevalence with sufficient accuracy to monitor the HIV epidemic. The accuracy of the estimates across all age groups is particularly important because knowledge of the age-related risk pattern provides the information on transmission patterns that is needed to design effective intervention programs. Because these methods were tested using data only from southern and eastern Africa where the HIV epidemic is mature and generalized, they may not work as well in regions where the epidemic is restricted to subsets of the population. Other factors that might affect their accuracy include the amount of international migration and the uptake of antiretroviral therapies. Nevertheless, with the increased availability of serial measurements of serological prevalence, these new methods for estimating HIV incidence from HIV prevalence could prove extremely useful for monitoring the progress of national HIV epidemics and for guiding HIV control programs. The authors include spreadsheets that can be used to calculate incidence by either method from consecutive survey data. Additional Information. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050080. The US National Institute of Allergy and Infectious Diseases provides information on HIV infection and AIDS The US Centers for Disease Control and Prevention provides information on global HIV/AIDS topics (in English and Spanish) The HIV InSite provides comprehensive and up-to-date information on all aspects of HIV/AIDS from the University of California San Francisco, including country reports on the AIDS epidemic in 195 countries, including Uganda, Zimbabwe, and Tanzania Avert, an international AIDS charity, provides information on all aspects of HIV/AIDS, including fact sheets on understanding HIV and AIDS statistics, and on HIV and AIDS in Africa The Demographic and Health Surveys program collects, analyzes, and disseminates information on health and population trends in countries around the world

Background The burden of non-communicable diseases (NCDs) is increasing in sub-Saharan Africa, but data available for intervention planning are inadequate. We determined the prevalence of selected NCDs and HIV infection, and NCD risk factors in northwestern Tanzania and southern Uganda. Methods A population-based cross-sectional survey was conducted, enrolling households using multistage sampling with five strata per country (one municipality, two towns, two rural areas). Consenting adults (≥18 years) were interviewed using the WHO STEPS survey instrument, examined, and tested for HIV and diabetes mellitus (DM). Adjusting for survey design, we estimated population prevalences of hypertension, DM, obstructive pulmonary disease, cardiac failure, epilepsy and HIV, and investigated factors associated with hypertension using logistic regression. Results Across strata, hypertension prevalence ranged from 16 % (95 % confidence interval (CI): 12 % to 22 %) to 17 % (CI: 14 % to 22 %) in Tanzania, and from 19 % (CI: 14 % to 26 %) to 26 % (CI: 23 % to 30 %) in Uganda. It was high in both urban and rural areas, affecting many young participants. The prevalence of DM (1 % to 4 %) and other NCDs was generally low. HIV prevalence ranged from 6 % to 10 % in Tanzania, and 6 % to 12 % in Uganda. Current smoking was reported by 12 % to 23 % of men in different strata, and 1 % to 3 % of women. Problem drinking (defined by Alcohol Use Disorder Identification Test criteria) affected 6 % to 15 % men and 1 % to 6 % women. Up to 46 % of participants were overweight, affecting women more than men and urban more than rural areas. Most patients with hypertension and other NCDs were unaware of their condition, and hypertension in treated patients was mostly uncontrolled. Hypertension was associated with older age, male sex, being divorced/widowed, lower education, higher BMI and, inversely, with smoking. Conclusions The high prevalence of NCD risk factors and unrecognized and untreated hypertension represent major problems. The low prevalence of DM and other preventable NCDs provides an opportunity for prevention. HIV prevalence was in line with national data. In Tanzania, Uganda and probably elsewhere in Africa, major efforts are needed to strengthen health services for the PREVENTION, early detection and treatment of chronic diseases. Electronic supplementary material The online version of this article (doi:10.1186/s12916-015-0357-9) contains supplementary material, which is available to authorized users.

Background Antiretroviral treatment restores physical functioning and may have an impact on fertility desires. Counseling is given to HIV positive women to create awareness and to provide information on pregnancy and delivery. The purpose of this study was to determine the incidence of pregnancy and factors that predict pregnancy among women of reproductive age receiving HIV care and treatment at a large urban center in western Uganda. Methods We conducted a retrospective cohort study using routinely collected data at the Immune Suppression (ISS) Clinic of Mbarara Regional Referral Hospital located in Mbarara District, western Uganda collected between January 2006 and June 2010. Women aged 15 to 50 years were eligible for analysis. The primary outcome was incidence of pregnancy calculated as number of pregnancies per 1000 person years (PY). Data was analyzed by calendar year and year of enrolment and used survival analysis to determine the predictors of pregnancy. Results A total of 3144 women were included with a median follow up of 12.5 months. The overall incidence rate was 90.7 pregnancies per 1000 person years. Incidence increased from 29.8 pregnancies per 1000 PY in 2006 to 122 pregnancies per 1000 PY in 2010 (p Conclusion Incidence of pregnancy among women receiving routine HIV care and treatment has increased and is almost comparable to that in the general population. Thus routine HIV care should integrate reproductive health needs for these women.